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Therefore, its diagnosis remains challenging and often relies on cardiac magnetic resonance imaging (MRI), which is usually performed only days after the index event, leading to delayed diagnosis and initiation of therapy. Coronary microembolization (CME) has been described as one of the major pathologies underlying MINOCA. However, the molecular mechanisms of CME remain poorly understood, resulting in a lack of rapid diagnostic tools and specific therapy approaches. In this review, we describe the molecular underpinnings of CME-derived MINOCA: an inflammatory environment inducing significant cellular damage that is conserved between cMI and MINOCA. While we note that some of these inflammatory and cellular death pathways are shared with cMI, we dissect mechanistic distinctions in CME-derived MINOCA such as dysregulated immune responses and higher miRNA activity. Most importantly, as molecular treatments for MI are currently in late-stage clinical trials, we can thus differentiate which therapeutics may work better for MINOCA. Thus, these findings can be used as a roadmap for diagnostic biomarkers and targeted therapeutic approaches for MINOCA.<\/jats:p>","DOI":"10.1007\/s00395-026-01189-2","type":"journal-article","created":{"date-parts":[[2026,7,4]],"date-time":"2026-07-04T15:26:29Z","timestamp":1783178789000},"page":"605-628","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Molecular mechanisms of coronary microembolization-induced MINOCA"],"prefix":"10.1007","volume":"121","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8647-3092","authenticated-orcid":false,"given":"Jasper","family":"Iske","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Henriette","family":"Thau","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joshua M.","family":"Mesfin","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christien M.","family":"Beez","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Petra","family":"Wolint","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jonas","family":"Hildinger","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nicolas","family":"Musigk","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Timo Z.","family":"Nazari-Shafti","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Adam","family":"Penkalla","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Volkmar","family":"Falk","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bettina","family":"Heidecker","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bertil","family":"Lindahl","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maximilian Y.","family":"Emmert","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nikola","family":"Cesarovic","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,7,4]]},"reference":[{"key":"1189_CR1","doi-asserted-by":"publisher","DOI":"10.1161\/jaha.119.014941","volume":"9","author":"A Abbate","year":"2020","unstructured":"Abbate A, Trankle CR, Buckley LF, Lipinski MJ, Appleton D, Kadariya D, Canada JM, Carbone S, Roberts CS, Abouzaki N, Melchior R, Christopher S, Turlington J, Mueller G, Garnett J, Thomas C, Markley R, Wohlford GF, Puckett L, Medina de Chazal H, Chiabrando JG, Bressi E, Del Buono MG, Schatz A, Vo C, Dixon DL, Biondi-Zoccai GG, Kontos MC, Van Tassell BW (2020) Interleukin-1 blockade inhibits the acute inflammatory response in patients with ST-Segment-elevation myocardial infarction. 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